Propranolol Dosing for Anxiety
For anxiety, propranolol is typically prescribed at 10-40 mg taken 1-3 times daily as needed, with a total daily dose ranging from 20-120 mg depending on symptom severity and individual response. 1, 2, 3
Dosing Guidelines
- Starting dose: 10-20 mg taken 30-60 minutes before anxiety-provoking situations or 20-40 mg daily divided into 2-3 doses for ongoing anxiety
- Maintenance dose: 40-80 mg daily in divided doses
- Maximum dose: Up to 120-160 mg daily may be used in severe cases, though higher doses increase risk of side effects
Dosing Based on Anxiety Type
- Performance/situational anxiety: 10-40 mg taken 30-60 minutes before the anxiety-provoking event
- Somatic anxiety symptoms: 40-80 mg daily in divided doses (more effective for physical symptoms like tremor, palpitations, sweating) 4
- Chronic anxiety with prominent physical symptoms: 80-160 mg daily in divided doses
Administration Considerations
- Immediate-release tablets: Typically dosed 2-3 times daily due to shorter half-life
- Extended-release formulations: Once-daily dosing possible (not a simple mg-for-mg substitute for immediate-release) 5
- Timing: For situational anxiety, administer 30-60 minutes before the anxiety-provoking event
Efficacy and Monitoring
- Most effective for anxiety with prominent somatic symptoms (tremor, palpitations, tachycardia) 3, 4
- Clinical response typically occurs within 1-2 hours of administration for somatic symptoms 3
- Less effective for purely psychological anxiety symptoms compared to benzodiazepines 4
- Monitor heart rate and blood pressure at follow-up visits
Important Precautions
- Cardiovascular assessment: Perform cardiovascular examination before initiating therapy (auscultation, peripheral pulses) 5
- Contraindications: Asthma, COPD, heart block, bradycardia, hypotension, heart failure
- Common side effects: Fatigue, dizziness, sleep disturbances, cold extremities 5, 6
- Mood effects: May cause or worsen depression in predisposed individuals 6
- Abrupt discontinuation: Avoid sudden discontinuation after prolonged use to prevent rebound symptoms
Clinical Pearls
- Propranolol primarily blocks peripheral manifestations of anxiety and works best when somatic symptoms predominate 3, 4
- Lower doses (20-40 mg) are often sufficient for situational anxiety 1
- Exercise may help reduce propranolol-induced mood disturbances 6
- Unlike benzodiazepines, propranolol does not cause dependence or tolerance, making it suitable for long-term use when needed 3
- May be particularly useful in patients who have not responded to or cannot tolerate benzodiazepines 2